ORIGINAL ARTICLE

ONLINE FIRST
Eliminating Preventable Death on the Battlefield
Russ S. Kotwal, MD, MPH; Harold R. Montgomery, NREMT; Bari M. Kotwal, MS; Howard R. Champion, FRCS;
Frank K. Butler Jr, MD; Robert L. Mabry, MD; Jeffrey S. Cain, MD; Lorne H. Blackbourne, MD;
Kathy K. Mechler, MS, RN; John B. Holcomb, MD

Objective: To evaluate battlefield survival in a novel com-
mand-directed casualty response system that compre-
hensively integrates Tactical Combat Casualty Care guide-
lines and a prehospital trauma registry.
Design: Analysis of battle injury data collected during
combat deployments.
Setting: Afghanistan and Iraq from October 1, 2001,
through March 31, 2010.
Patients: Casualties from the 75th Ranger Regiment, US
Army Special Operations Command.
Main Outcome Measures: Casualties were scruti-
nized for preventable adverse outcomes and opportuni-
ties to improve care. Comparisons were made with De-
partment of Defense casualty data for the military as a
whole.
Results: A total of 419 battle injury casualties were in-
curred during 7 years of continuous combat in Iraq and
8.5 years in Afghanistan. Despite higher casualty severity
indicated by return-to-duty rates, the regiment’s rates of
10.7% killed in action and 1.7% who died of wounds were
lower than the Department of Defense rates of 16.4% and
5.8%, respectively, for the larger US military population
(P=.04 and P=.02, respectively). Of 32 fatalities incurred
by the regiment, none died of wounds from infection, none
were potentially survivable through additional prehos-
pital medical intervention, and 1 was potentially surviv-
able in the hospital setting. Substantial prehospital care was
provided by nonmedical personnel.
Conclusions: A command-directed casualty response sys-
tem that trains all personnel in Tactical Combat Casualty
Care and receives continuous feedback from prehospital
trauma registry data facilitated Tactical Combat Casualty
Care performance improvements centered on clinical out-
comes that resulted in unprecedented reduction of killed-
in-action deaths, casualties who died of wounds, and pre-
ventable combat death. This data-driven approach is the
model for improving prehospital trauma care and casu-
alty outcomes on the battlefield and has considerable im-
plications for civilian trauma systems.
Arch Surg. 2011;146(12):1350-1358. Published online
August 15, 2011. doi:10.1001/archsurg.2011.213

Author Affiliations: US Army
Special Operations Command,
Fort Bragg, North Carolina
(Dr R. S. Kotwal,
Mr Montgomery, and
Ms B. M. Kotwal); Uniformed
Services University of the
Health Sciences, Bethesda,
Maryland (Dr Champion); and
US Army Institute of Surgical
Research, Fort Sam Houston
(Drs Butler, Mabry, Cain, and
Blackbourne), Rural and
Community Health Institute,
Texas A&M Health Science
Center, Bryan (Ms Mechler),
and Center for Translational
Injury Research, University of
Texas Health Science Center,
Houston (Dr Holcomb).
T
HE 75TH RANGER REGIMENT
is the US Army’s premier
raid force. Comprising more
than 3500 personnel, the
regiment conducts joint spe-
cial operations combat missions to include
airborne, air assault, and other direct-action
raids to seize key targets, destroy strategic
facilities, and capture or kill enemy forces.1
Providingcaretocasualtiesduringsuchmis-
sions is a major challenge.
See Invited Critique
at end of article
Historically, approximately 90% of
combat-related deaths occur prior to a ca-
sualty reaching a medical treatment facil-
ity (MTF).2,3 The combat environment has
many factors that affect prehospital care,
including temperature and weather ex-
tremes, severe visual limitations imposed
by night operations, logistical and combat-
related delays in treatment and evacua-
tion, lack of specialized medical care pro-
viders and equipment near the scene, and
lethal implications of opposing forces.
Thus, a tailored approach to prehospital
trauma care must be used when conduct-
ing combat operations.
Combat casualty care in World War II,
the Korean War, and the Vietnam War re-
sulted in incremental and significant im-
provement of civilian trauma care and sys-
tems.4 Conversely, assimilating civilian
paradigms such as Advanced Trauma Life
Support into the combat setting exposed
deficiencies in military prehospital trauma
care during conflicts in Iraq and Somalia
in the early 1990s. Subsequent congres-
sional inquiries and after-action reports led
to a better understanding of profound
medical differences between civilian and
military environments.5-9
Emerging from these reviews and from
Vietnam War casualty data analysis was an
article entitled “Tactical Combat Casualty
Care in Special Operations,” which pre-
sented prehospital trauma care guidelines
customized for the battlefield.6 These Tac-

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 tical Combat Casualty Care (TCCC) guidelines empha-
sized 3 objectives: (1) treat the patient, (2) prevent addi-
tional casualties, and (3) complete the mission. It then gave
3 phases of care: (1) care under fire, (2) tactical field care,
and (3) casualty evacuation care. These centered on pre-
venting the 3 major, potentially survivable causes of death:
(1) extremity hemorrhage exsanguination, (2) tension pneu-
mothorax, and (3) airway obstruction.2,3,6 Because TCCC
guidelines diverged from accepted mainstream civilian stan-
dards for Advanced Trauma Life Support–based prehos-
pital care,6 initial acceptance in the US military was slow
despite a need for treatment protocols designed specifi-
cally for the tactical component of the combat environ-
ment.10,11 In contrast, Army Rangers and Navy SEALs (Sea,
Air, and Land Teams) extensively implemented TCCC on
its inception.12 The TCCC guidelines have continued to
evolve through a Committee on TCCC,13-15 founded in 2001
and currently reporting through the Defense Health Board
to the Assistant Secretary of Defense for Health Affairs.
Tactical leaders are combat unit leaders at the battle-
front. In 1998, a tactical leader and commander of the 75th
Ranger Regiment, then COL Stanley McChrystal, insti-
tuted a directive for all Rangers to focus on 4 major train-
ing priorities termed the “Big Four”: (1) marksmanship,
(2) physical training, (3) small unit tactics, and (4) medi-
cal training. Thus, medical readiness immediately became
a highlighted area of command interest, affording the timely
opportunity to establish a casualty response system inte-
grating initial and recurrent TCCC training into pro-
grams of instruction, training exercises, and contingency
planning at all levels.12,16-18 This complete integration of
TCCC, which included TCCC training of all assigned per-
sonnel together with tactical leader assumption of respon-
sibility for the casualty response system, was and remains
an approach that is substantially different from casualty pre-
paredness experienced throughout the rest of the Depart-
ment of Defense (DoD). Although most of the US military
has now included TCCC in combat medic education, they
have largely continued medical training in their previous
model—lacking comprehensive, all-inclusive, command-
directed casualty response systems—leaving medical care
to the medics, with nominal input from tactical leaders and
without continuous feedback from a registry to guide per-
formance improvements at the combat unit level.
Although the Joint Theater Trauma System and Joint
Theater Trauma Registry (JTTR) were successfully imple-
mented to oversee process improvements in military hos-
pital-based care and outcomes,19-21 a similar global ap-
proach to military prehospital care is lacking. In addition
to a comprehensive command-directed TCCC training
program institutionalized prior to the onset of conflict
in Afghanistan and Iraq,12,16-18 the regiment integrated con-
tinuous performance improvement concepts. The nucleus
of this approach is a Web-based prehospital trauma reg-
istry (PHTR), the only one of its kind that collects data
that have historically been difficult to capture.7,22-24 The
PHTR is a software tool specifically designed to capture
prehospital injury and treatment data with integrated fea-
tures for basic analysis and instant graphing.23 Concep-
tually, the PHTR was modeled after registries required
at trauma centers throughout the world but was custom-
ized for data germane to the combat casualty.
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We hypothesized that training the entire fighting force
in TCCC, tactical leader ownership of the casualty re-
sponse system, and near-real-time feedback from PHTR
data would improve outcomes for combat casualties.
METHODS
A casualty is defined in this study as a member of the 75th Ranger
Regiment who sustained a battle injury for which criteria were
met for award of the Purple Heart medal.25 Nonbattle injuries
were excluded. Casualties are divided into wounded in action
(WIA) and killed in action (KIA). The WIA casualties are fur-
ther divided into died of wounds (DOW), returned to duty in
less than 72 hours (RTD), and non-DOW and non-RTD evacu-
ated to an MTF within 3 days.26 A KIA casualty is one who died
prior to reaching an MTF or is dead on arrival. A DOW casu-
alty is one who died after reaching an MTF.
Main outcomes include potentially survivable deaths and
traditional combat casualty care statistics, RTD percentage, KIA
percentage, DOW percentage, and case fatality rate,26 which are
compared with DoD figures.27 Secondary outcomes include use
of TCCC treatment protocols. Independent variables include
establishment of a command-directed comprehensive TCCC
program with performance improvement through the PHTR.
Additional hypothesis testing was accomplished using the ␹2
test of significance set at P⬍.05.
More than 8000 combat missions, primarily direct-action raids,
were conducted by the 75th Ranger Regiment in Afghanistan and
Iraq between October 1, 2001, and March 31, 2010. Prehospital
casualty and treatment data from these missions were collected
directly from medics, most within 72 hours of an event, on a Ranger
Casualty Card, adopted later as DA Form 7656. Data were then
entered into the PHTR and cross-referenced with other opera-
tional sources to include Purple Heart packets, casualty track-
ers, mission logs, medical records, JTTR data, and Armed Forces
Institute of Pathology autopsies. Medical and tactical leaders scru-
tinized casualties for opportunities to improve care through for-
mal investigation of data from the PHTR, JTTR, and Armed Forces
Institute of Pathology. Process of care was analyzed for appro-
priateness and effectiveness. Casualties and treatments were criti-
cally analyzed within the context of the tactical mission. Casu-
alties were followed to final disposition. Deaths were analyzed
in detail for performance improvement opportunities. Compari-
sons with similar military prehospital data could not be made, as
they do not exist.
Institutional review boards at the Texas A&M Health Sci-
ence Center and the US Army Medical Research and Materiel
Command provided approval to conduct this study.
RESULTS
Battle injury data were collected from October 1, 2001,
to March 31, 2010, for Operation Enduring Freedom in
Afghanistan and from March 15, 2003, to March 31, 2010,
for Operation Iraqi Freedom. Casualty cards were avail-
able for 74% of casualties, JTTR data for 78% of evacu-
ated casualties, and Armed Forces Institute of Pathol-
ogy autopsy data for 100% of fatalities. Demographic,
injury, and outcome data were obtained through other
operations sources for the 26% of casualties without com-
pleted cards. By combining data sources, 100% of casu-
alties had adequate data available for analysis. Casual-
ties who did not seek prehospital care and medics limited
by the mission accounted for missing casualty cards.
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 Of the 419 casualties incurred, including 239 (57%)
from Operation Iraqi Freedom and 180 (43%) from Op-
eration Enduring Freedom, 387 (92%) survived
(Figure 1). All casualties were male, with age at time
of injury ranging from 18.9 to 52.9 years. Infantrymen
were most frequently injured (86%), followed by medi-
cal personnel (5%) and artillerymen (3%). Overall demo-
graphic characteristics were reflective of other military
combat regiments and brigades.
Mechanisms of injury included explosions—
improvised explosive device (IED) and non-IED—
resulting in blast, ballistic, and blunt trauma28 as well as
gunshot wound injuries and aircraft and ground vehicle
blunt trauma injuries. Non-IEDs were the most fre-
quent cause of injury (43%). Gunshot wound injuries ac-
counted for half of all deaths (Figure 2). None of the
32 deaths resulted from the 3 major potentially surviv-
able causes of death (extremity hemorrhage exsangui-
nation, tension pneumothorax, and airway obstruc-
tion) defined in the literature.2,3,6,29-31 One casualty with
potentially survivable extremity wounds died of post-
surgical complications following evacuation.
Although the DoD does not have a process to system-
atically evaluate potentially survivable deaths, the regi-
ment’s 3% rate (1 in 32) is significantly lower than the
24% rate (232 in 982) previously reported for a subset
of US fatalities from Operation Enduring Freedom and
Operation Iraqi Freedom (␹21 = 6.2, P = .01).31 Bench-
mark statistics for RTD, KIA, DOW, and case fatality rate
provided in Table 1 and Table 2 depict decreased com-
bined theater and Operation Iraqi Freedom KIA and DOW
rates for the 75th Ranger Regiment compared with US
ground troop rates for the same period (P⬍.05). The RTD
rates were lower in surviving Rangers, likely signifying
increased severity of wounding.
Most interventions were for hemorrhage control
(Table 3), 26% of which were applied by nonmedical per-
sonnel. A total of 89 tourniquets were applied to 66 casu-
alties, with no resultant complications, which is consis-
tent with cited safety.32,33 Nonmedical personnel accounted
for 42% of tourniquet applications. Of casualties with tour-
niquets, almost all reached the next level of care alive (95%)
and ultimately survived (94%). Only 16% of these survi-
vors had injuries resulting in limb amputations, 8 with
1-limb amputation (7 below the knee and 1 below the el-
bow) and 2 with 2-limb amputations (3 above and 1 be-
low the knee). A total of 37 hemostatic dressings were ap-
plied to 30 casualties, with 71% reaching the next level of
care alive and ultimately surviving.
Fewer than 10% of casualties received advanced airway
or breathing interventions (Table 4). Advanced airway pro-
cedures (intubation or cricothyroidotomy) were performed
in 14 casualties in extremis, of whom 4 reached a hospital
alive. Attempted intubations were converted to successful
surgical airways in 3 instances, but these casualties died of
their wounds prior to reaching a hospital. Advanced breath-
ing interventions (thoracentesis or thoracostomy) were pro-
vided to 20 casualties, of whom 55% survived to reach the
next level of care and 50% ultimately survived. No casu-
alties died of airway obstruction or tension pneumothorax.
Prehospital vascular access was obtained for 90 casu-
alties (Table 5), of whom 61% received intravenous fluid
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A Died Lived
100
80
Casualties, No.
60
40
20
0
B OIF OEF
100
80
Casualties, No.
60
40
20
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
(October-December) (January-March)
Year
Figure 1. The 75th Ranger Regiment casualties by survival (A) and theater of
operation (B) between October 1, 2001, and March 31, 2010. OIF indicates
Operation Iraqi Freedom; OEF, Operation Enduring Freedom. Of the 419
casualties incurred, 32 (8%) died and 387 (92%) lived; 239 (57%) occurred
in OIF and 180 (43%) occurred in OEF.
and 39% received vascular access only. Of casualties re-
suscitated with intravenous fluid, almost all reached the
next level of care alive (96%) and ultimately survived (93%),
with 64% receiving crystalloid, 27% colloid, and 9% both.
Of casualties who received vascular access only, 91% reached
the next level of care alive and also ultimately survived. Ster-
nal intraosseous access was used in 1 casualty.
Consistent with evolving TCCC guidelines,6,13-15 trends
over time show a decrease in intravenous fluid use and
an increase in obtaining vascular access only for casual-
ties in shock or requiring intravenous medications.
Prehospital antibiotics and analgesics were provided to
reduce risk of infection and pain syndromes.6,13-15,34-37 A total
of 113 casualties received antibiotics, including 81 who self-
administered oral combat wound pill packs consisting of
a fluoroquinolone and two analgesics (acetaminophen and
either celecoxib or meloxicam),13-15,34 28 who received par-
enterally administered antibiotics (75% ertapenem so-
dium and 25% a cephalosporin), and 4 who received both.
No adverse reactions to antibiotics were reported. Of all
casualties, 25 (6%) developed an infection during hospi-
talization. Additionally, 6% of casualties who did not re-
ceive prehospital antibiotics developed an infection, com-
pared with 4% of those who did receive prehospital
antibiotics. Most casualties with an infection (80%) did not
receive prehospital antibiotics. Almost all infections (96%)
occurred after evacuation from the combat theater, and
nearly half (48%) were cultured as Acinetobacter. One ca-
sualty progressed to sepsis but survived. No casualties were
categorized as DOW from infection.
A total of 146 casualties received prehospital analge-
sics other than combat wound pill packs. These include
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 A GSW and explosives B
(non-IED), 3%

Blunt
Blunt
9%d
6%
Explosives
(non-IED)
9%c

GSW Explosives GSW

24% (non-IED) 50%a
43%

Explosives
(IED)
31%b
Explosives
(IED)
24%

Figure 2. The 75th Ranger Regiment casualties (n=419) (A) and fatalities (n = 32) (B) by mechanism of injury between October 1, 2001, and March 31, 2010. Due
to rounding, percentages may not total 100%. GSW indicates gunshot wound; IED, improvised explosive device. a Of casualties who died of GSW injuries, 44%
were from coronal trajectory transthoracic wounds, 31% were from sagittal trajectory transcranial wounds, 13% were from coronal trajectory transthoracic and
neck wounds, and 6% were from sagittal trajectory extremity wounds. b Of casualties who died of IED injuries, all had massive head and extremity wounds and
90% also had massive torso wounds. c Non-IED explosives include mortars, grenades, and rocket-propelled grenades. Of casualties who died of non-IED explosive
injuries, all had massive torso and extremity wounds and 33% also had massive head wounds. d Blunt trauma includes nonblast combat-related aircraft and
vehicle incidents. Of casualties who died of blunt trauma injuries, all had massive head, torso, and extremity wounds with a crush component.

Table 1. Comparison of Battle Injuries in the 75th Ranger Regiment vs Total US Military Ground Troops Between October 1, 2001,
and March 31, 2010

Casualties in 75th Ranger Regiment, No. Casualties in US Military Ground Troops, No. a
(n=419) (n = 43 311)

WIA WIA

Theater of Non-DOW Non-DOW

Operation Total b RTD and Non-RTD DOW KIA Total b RTD and Non-RTD DOW KIA
OEF 167 76 89 2 13 5266 2294 2831 141 586
OIF 224 81 141 2 15 29 952 17 307 11 881 764 2478
Total 391 157 230 4 28 35 218 19 601 14 712 905 3064

Abbreviations: DOW, died of wounds; KIA, killed in action; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom; RTD, returned to duty in less than
72 hours; WIA, wounded in action.
a Obtained through the US Department of Defense, Defense Manpower Data Center.27
b Total WIA = RTD ⫹[non-DOW and non-RTD] ⫹DOW.

82 casualties who were administered oral transmucosal
fentanyl citrate, 23 who received morphine sulfate, 27
who received both, and 14 who received other analge-
sics (hydromorphone hydrochloride, hydrocodone bi-
tartrate, ketorolac tromethamine, or ibuprofen). Of the
50 casualties who were administered morphine, 30 (60%)
received it intravenously and 20 (40%) intramuscu-
larly. Only 1 casualty, who received oral transmucosal
fentanyl and morphine, was noted to have other-than-
minimal adverse effects.36
COMMENT
The Rangers are the only DoD force that has institution-
alized a unitwide casualty response system using the fol-
lowing integrated 3-part approach: (1) TCCC training
for all personnel, (2) tactical leader ownership of the pre-
hospital casualty response system, and (3) use of PHTR
data to rapidly update TCCC protocols, force health pro-
tection, and training. Focused on increasing battlefield
casualty survival, this approach enables performance im-
provements through data-driven multidisciplinary re-
view and consensus regarding best practices.
Because approximately 90% of all battlefield deaths
occur prior to the casualty reaching an MTF,2,3 process
improvements directed toward prehospital care have the
best opportunity to improve survival from combat in-
jury. Data on potentially survivable deaths from the Viet-
nam War suggest that 60% were from extremity hemor-
rhage exsanguination, 33% from tension pneumothorax,
and 7% from airway obstruction.2,29-31 Despite wide-
spread recognition of these causes and overall US mili-
tary case fatality rate reduction from 19.1 in World War
II to 15.8 in the Vietnam War to 10.3 in current con-

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 Table 2. Comparison of Proportional Statistics for Battle Injuries in the 75th Ranger Regiment vs Total US Military Ground Troops
Between October 1, 2001, and March 31, 2010

75th Ranger Regiment US Military Ground Troops

(n=419) (n = 43 311)

Statistic Overall OEF OIF Overall OEF OIF

RTD, % a 40 b 46 36 b 56 44 58
KIA, % c 10.7 b 12.5 9.5 b 16.4 16.5 16.4
DOW, % d 1.7 b 2.2 1.4 b 5.8 4.7 6.0
CFR e 7.6 8.4 7.1 10.3 12.4 10.0

Abbreviations: CFR, case fatality rate; DOW, died of wounds; KIA, killed in action; OEF, Operation Enduring Freedom; OIF, Operation Iraqi Freedom;
RTD, returned to duty in less than 72 hours.
a The RTD percentage (RTD/wounded in action ⫻100) defines minor wounds.26 The differences between overall and OIF values for the 2 groups were
statistically significant (␹12=11.6, P ⬍.001; and ␹12=12.8, P⬍.001), indicating fewer minor wounds in the Ranger populations given the same period. However, the
difference between OEF values was not statistically significant (␹12= 0.058, P = .81).
b Statistically significant (P ⬍.05).
c The KIA percentage ([KIA/(KIA ⫹wounded in action−RTD)] ⫻ 100) provides a potential measure of weapon lethality, effectiveness of prehospital medical care,
and availability of tactical evacuation.26 All Ranger values appear to be lower compared with the US military ground troops. The differences between overall and
OIF values for the 2 groups were statistically significant (␹12=4.3, P = .04; and ␹12= 4.2, P = .04). However, the difference between OEF values was not statistically
significant (␹12= 0.63; P=.43).
d The DOW percentage ([DOW/(wounded in action−RTD)] ⫻100) provides a potential measure of the precision of initial prehospital triage and care, optimization
of evacuation procedures, and application of a coordinated trauma system as well as the effectiveness of medical treatment facility care.26 Although all Ranger
values appear to be lower compared with US military ground troops, only the differences in overall and OIF values were statistically significant (␹12= 5.9, P=.02;
and ␹12= 4.2, P = .04). The OEF value was not statistically significant (␹12= 0.71, P = .40). Also of note, for US military ground troops, the DOW percentage has
remained less than 5% during the past half century; however, in this study it was found to be higher overall and in OIF.
e The CFR ([(KIA⫹DOW)/(KIA ⫹ wounded in action)] ⫻100) provides a potential measure of overall battlefield lethality in a battle injury population.26 Although
all Ranger values appear to be lower compared with US military ground troops, none were found to be statistically significant (␹12= 2.5, P = .11; ␹12= 1.9, P=.17; and
␹12= 1.6, P = .21).

Table 3. Hemorrhage Control Interventions Administered by 75th Ranger Regiment Personnel by Provider Level During Care Under
Fire and Tactical Field Care Phases of Tactical Combat Casualty Care Between October 1, 2001, and March 31, 2010 a

Care Provider Level, No.

Intervention RFR Nonmedic EMT Medic Medical Officer Total, No.

Pressure dressing b 33 16 136 21 206
Gauze dressing 28 16 121 23 188
Tourniquet c 27 10 49 3 89
Hemostatic dressing d 3 1 26 7 37
Total 91 43 332 54 520

Abbreviations: EMT, emergency medical technician; RFR, Ranger First Responder.

a Nonmedical personnel provided 26% (134/520) of all hemorrhage control interventions and 42% (37/89) of all tourniquets.
b Primarily Emergency Trauma Dressings (North American Rescue, LLC, Greer, South Carolina).
c Primarily Combat Application Tourniquets (Composite Resources, Rock Hill, South Carolina).
d Primarily HemCon bandages (HemCon Medical Technologies, Inc, Portland, Oregon) and Combat Gauze (Z-Medica Corp, Wallingford, Connecticut).

flicts described in this study, these 3 major causes of death
continue to be present in Afghanistan and Iraq.26,30,31 Hol-
comb et al30 identified opportunities to improve care in
12 of 82 deaths (15%) among Special Operations Forces.
In a review of 982 deaths, Kelly et al31 reported 24% of
deaths as potentially survivable, with opportunity to im-
prove care equally distributed between prehospital and
hospital settings. Although it cannot be absolutely quan-
tified as resulting from their casualty response system,
an overall case fatality rate of 7.6 coupled with the elimi-
nation of prehospital preventable deaths validates to a
notable degree the Ranger training approach (Table 6).
Training for TCCC was initiated by the Rangers in 1997
and formed the basis for 2 programs of instruction, Ranger
First Responder (RFR) and Casualty Response Training for
RangerLeaders.12,16-18 Becausecareunderfiremustbesimple,
direct, and conditioned into the provider, RFR emphasizes
repetitive hands-on application of TCCC lifesaving skills
incorporated into realistic scenario-based learning. Every-
one on the battlefield, not just medics, has the potential to
be a casualty or to be the first person to encounter a casu-
alty; thus, RFR is mandated for all personnel in the regiment
regardless of their role.18 This concept is best illustrated by
the fact that 26% of hemorrhage control interventions in
this study, including 42% of tourniquets, were applied by
nonmedical personnel at the point of wounding, probably
decreasing the necessity for additional prehospital resus-
citation and certainly contributing to no preventable deaths
due to extremity hemorrhage exsanguination.
Because the tactical commander manages all re-
sources dedicated to preparing for and completing a mis-
sion, it is this nonmedical leader who is ultimately re-
sponsible for the prehospital casualty response system.
This concept differentiates RFR and Casualty Response
Training for Ranger Leaders from other medical pro-
grams. The goal is to educate all on the operational con-

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 Table 4. Airway and Breathing Interventions Administered by 75th Ranger Regiment Personnel During Tactical Field Care Phases
of Tactical Combat Casualty Care and Associated Outcomes Between October 1, 2001, and March 31, 2010

Casualties, No.

Intervention WIA DOW KIA

Airway
NPA only 7 0 0
King-LT intubation only a 0 0 2
NPA ⫹King-LT/Combitube replaced by endotracheal intubation a 2 0 0
Surgical cricothyroidotomy only 1 1 5
Endotracheal intubation replaced by surgical cricothyroidotomy 0 0 3
Breathing
Chest seal only 24 0 0
Needle thoracentesis only 2 1 0
Chest seal⫹needle thoracentesis 6 0 7
Chest seal⫹needle thoracentesis ⫹ tube thoracostomy 2 0 2

Abbreviations: DOW, died of wounds; KIA, killed in action; NPA, nasopharyngeal airway; WIA, wounded in action.
a The King-LT is from King Systems, Noblesville, Indiana; the Combitube is from Kendall-Sheridan Catheter Corp, Argyle, New York.

Table 5. Vascular Access and Intravenous Fluid Administered by 75th Ranger Regiment Personnel During Tactical Field Care Phases
of Tactical Combat Casualty Care Between October 1, 2001, and March 31, 2010

Intervention IVF Dose, mL Casualties, No.

Saline lock only NA 35
Saline lock and IVF NA 55
Normal saline 250 1
500 25 a
1000 6
1500 1
Hextend b 250 2
500 12 a,c
1000 1
Normal saline⫹ Hextend b 500⫹ 500 3
1000⫹ 250 1
500⫹ 100 1a
Lactated ringers 500 2a

Abbreviations: IVF, intravenous fluid; NA, not applicable.

a Four casualties received 2 saline locks and IVF.
b Hextend is from Hospira, Inc, Lake Forest, Illinois.
c One casualty received IVF through a FAST-1 sternal intraosseous device (Pyng Medical Corp, Richmond, British Columbia, Canada).

Table 6. Tactical Combat Casualty Care Training in the 75th Ranger Regiment

Title Who Training

Ranger First Responder
Casualty battle drills
Casualty response training
for Ranger leaders
EMT-B program
Ranger medic
All personnel
All personnel
All small unit leaders and commanders
Nonmedics (1 in 10 personnel)
Medics (1 in 30 personnel)
Initial and annual TCCC point-of-wounding training emphasizing
hemorrhage control
Casualty care and evacuation rehearsals integrated into tactical
training
Contingency planning and management of casualty response
and evacuation procedures
4-wk civilian EMT-B course with refresher training that includes
TCCC and Prehospital Trauma Life Support training
Assigned personnel who have completed a 16-wk US Army
combat medic training program and an EMT-P or 26-wk
Special Operations Combat Medic training program

Abbreviations: EMT-B, Emergency Medical Technician Basic; EMT-P, Emergency Medical Technician Paramedic; TCCC, Tactical Combat Casualty Care.

sequences of a casualty and how to mitigate adverse out-
comes for both the casualty and the mission. A key
underpinning of this training is the use of the term ca-
sualty response rather than medical training, as it imparts
a collective requirement for the entire fighting force to
take action as with any other battle drill. When a casu-
alty occurs on a mission, the event is a tactical problem
to be solved and not just an isolated medical issue.
Casualty battle drills are imbedded into small unit tac-
tics and tactical training exercises. Realism is maximized

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 by introducing the turbulence of casualty scenarios into the
natural flow of tactical training. Mastery of this training in-
stills confidence in the casualty response system, increas-
ing unit morale and cohesion as all come to realize that the
best possible care will be provided promptly by fellow sol-
diers on the battlefield, thus putting medical capability on
par with fighting capability.
Medical training in the DoD is not consistent among the
services and between units. In the US Army, a centralized
16-week medical course is used to initially train combat
medics. Thereafter, sustainment medical training, tactical
training, and employment of combat medics are decen-
tralized and the responsibility of the individual line com-
mander. Tactical line commanders who understand the re-
quirements and importance of the casualty response system
will provide the time, training, and equipment necessary
to ensure that medical personnel, and ultimately all as-
signed personnel, are sufficiently prepared to receive com-
bat casualties. This is not the norm, however, as many do
not realize this responsibility or recognize the operational
importance of casualty care.
A standardized Ranger medic training pathway was
initially established in 1998.16 This pathway was refined
to include Emergency Medical Technician Paramedic or
26-week Special Operations Combat Medic38 training fol-
lowed by recurrent sustainment, assessment, and vali-
dation training that maximizes use of human patient simu-
lators, live tissue training, realistic trauma lanes, and major
metropolitan trauma center rotations. To provide a foun-
dation for medic knowledge, the first official Ranger Medic
Handbook was distributed throughout the regiment in
2001.17 This TCCC-based handbook, updated periodi-
cally,39 provides medics with guidelines, protocols, and
procedures for optimizing prehospital care.
A 4-week Emergency Medical Technician Basic pro-
gram was mandated for 1 in 10 nonmedics as a means to
bridge the gap between RFRs and Ranger medics.18 Re-
current sustainment training includes the Prehospital
Trauma Life Support course, as this course has evolved
to include military and TCCC-based protocols and pro-
cedures.15 This Emergency Medical Technician Basic pro-
gram not only expanded medical capabilities, it also cre-
ated more medically knowledgeable tactical leaders as they
advanced through the leadership ranks.
In the regiment, it is now common and expected for
nonmedical personnel to rapidly and accurately man-
age life-threatening extremity hemorrhage. This immea-
surably improves tactical leader awareness and respon-
sibility for their casualty response system. Tactical leaders
now hold themselves accountable for casualties and ca-
sualty response training through self-assessment and unit
status reports. Demonstrated medical proficiency is re-
garded to be as important as weapon proficiency. Well-
informed nonmedical leaders may ultimately play the most
important role in reducing preventable death on the battle-
field. In fact, intensive training, contingency planning,
and an appropriate tactical response to casualty sce-
narios may have saved more lives than the medical in-
terventions themselves.
Prehospital record keeping and the availability of such
data are notoriously challenging on the battlefield.7,24 In
2001, the regiment began work on a minimalistic data
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set captured through a Ranger Casualty Card collection
program. The template for this card was adopted by the
US Army in 2009 as DA Form 7656 TCCC Casualty Card.
With direct support from Congress, funds were allo-
cated for a combat trauma registry modeled after trauma
registry concepts developed during the past 40 years in
the civilian sector.40,41 The hospital effort centered on in-
patient medical treatment facilities through the JTTR,19-21
and the prehospital effort centered on a tactical unit
through the PHTR.22,23
The primary purpose of the PHTR is to provide tac-
tical leaders and medical care providers with near-real-
time trends, reports, and analysis for lessons learned, qual-
ity assurance, and performance improvements designed
to immediately reduce morbidity and mortality on the
battlefield. Commanders quickly make data-based deci-
sions to optimize casualty response and force protec-
tion, resulting in rapid treatment protocol modification
and body armor evolution. Resultant directed procure-
ment of medical devices and personal protective equip-
ment is data driven, peer reviewed, and cost-effective.
CONCLUSIONS
Historically, war and conflict have prompted advances
in both individual techniques and effective systems to im-
prove trauma care.42-44 The current war is no exception.
Prehospital advances implemented by TCCC have im-
proved the probability that casualties will arrive at the
hospital alive so they can benefit from the trauma care
system now in place.13-15,32,33,45-47 However, not all oppor-
tunities have been realized. The remaining challenge is
to refine performance improvements and best practices
through systemwide prehospital data collection.
The TCCC guidelines represented a paradigm shift
away from civilian prehospital care practices. The casu-
alty response system described in this study is also a shift
away from traditional US military practices. Despite the
lethality of modern-day warfare, the 75th Ranger Regi-
ment’s implementation of a comprehensive casualty re-
sponse system sustained by focused training directed by
tactical leaders using data from a unit-based PHTR has
resulted in historically low casualty rates for a frontline
unit of its type, to include virtual elimination of prevent-
able combat death. This approach has been recom-
mended by the Defense Health Board for implementa-
tion by combatant units throughout the DoD.48
Performance improvements in prehospital care are ac-
tively migrating from the current battlefield to civilian
practice. Implementing these initiatives in concert with
detailed documentation and analysis may have pro-
found implications for civilian prehospital trauma train-
ing, care, and preventable death, especially in light of the
fact that equivalent epidemiological studies on poten-
tially survivable death from trauma in the civilian pre-
hospital environment are sparse, and none have docu-
mented a pathway for successful elimination of
preventable death. A civilian prehospital system that in-
tegrates first responder skills throughout a community
and enacts performance improvement through a regis-
try may also eliminate preventable death.
WWW.ARCHSURG.COM
 Accepted for Publication: April 25, 2011.
Published Online: August 15, 2011. doi:10.1001
/archsurg.2011.213
Correspondence: Russ S. Kotwal, MD, MPH, US Army
Special Operations Command, 2929 Desert Storm Dr, Fort
Bragg, NC 28310 (russ.kotwal@us.army.mil).
Author Contributions: Study concept and design: R. S. Kot-
wal, Cain, and Mechler. Acquisition of data: R. S. Kot-
wal, Montgomery, B. M. Kotwal, and Cain. Analysis and
interpretation of data: R. S. Kotwal, Montgomery, Cham-
pion, Butler, Mabry, Blackbourne, and Holcomb. Draft-
ing of the manuscript: R. S. Kotwal, B. M. Kotwal, Cham-
pion, Mabry, and Blackbourne. Critical revision of the
manuscript for important intellectual content: R. S. Kot-
wal, Montgomery, Champion, Butler, Cain, Black-
bourne, Mechler, and Holcomb. Statistical analysis: R. S.
Kotwal. Administrative, technical, and material support: R.
S. Kotwal, Montgomery, B. M. Kotwal, Butler, Mabry, and
Blackbourne. Study supervision: R. S. Kotwal, Montgom-
ery, Blackbourne, and Holcomb.
Financial Disclosure: None reported.
Disclaimer: The views, opinions, and findings con-
tained in this report are those of the authors and should
not be construed as official or reflecting the views of the
DoD unless otherwise stated. Citations of commercial
products or organizations do not constitute an official
DoD endorsement or approval of the products or ser-
vices of these organizations. This report was approved
for public release by the US Army Special Operations Com-
mand Operational Security Office and the Public Affairs
Office on October 8, 2010.
Previous Presentation: The abstract was presented at the
2011 Combat Trauma Innovation Conference; January
18, 2011; London, England.
Additional Information: This article is dedicated to SFC
Marcus V. Muralles, a former 75th Ranger Regiment Spe-
cial Operations Combat Medic who was killed in action
while serving with the 160th Special Operations Avia-
tion Regiment in Afghanistan on June 28, 2005, and SGT
Jonathan K. Peney, a Special Operations Combat Medic
who was killed in action while serving with the 75th
Ranger Regiment in Afghanistan on June 1, 2010.
AdditionalContributions:WeacknowledgetheTexasA&M
Health Science Center Rural and Community Health Insti-
tute for their collaboration on the PHTR; the JTTR and the
Armed Forces Institute of Pathology for providing casualty
outcomedata;andallseniorRangerSpecialOperationsCom-
bat Medics whose practical experiences and perspectives
contributed immeasurably to the development and imple-
mentation of Ranger medical training programs and the
PHTR. Most importantly, we especially recognize the sac-
rifices of the casualties depicted in this article as well as their
fellow Rangers who provided care to them.
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INVITED CRITIQUE
Innovative Leadership of Casualty Care
A lan Keith of Genetech stated, “Leadership is ul-
timately about creating a way for people to con-
tribute to making something extraordinary hap-
pen.”1 Kotwal et al2 report on a remarkable commitment
to casualty care by the 75th Ranger Regiment. The Rang-
ers coupled a novel approach to combat casualty care with
modern continuous process improvement. When this was
applied in battle, the process resulted in the lowest mor-
tality rate, especially the preventable mortality rate, in
the Armed Forces.
The authors highlight that the transference of Ad-
vanced Trauma Life Support from civilian settings into
combat exposed significant deficits in battleground pre-
hospital care going back as far as the 1993 fighting in So-
malia. The deficiencies of civilian Advanced Trauma Life
Support were quickly addressed. In 1996, the TCCC
guidelines were published; they took into account is-
sues unique to battle such as prevention of additional ca-
sualties, mission completion, and the tactical chal-
lenges of evacuations under fire and focused medically
on the 3 major causes of preventable death: hemorrhage
from extremity wounds, tension pneumothorax, and air-
way problems. Unfortunately, the military as a whole was
slow to adopt the TCCC guidelines, and only the Spe-
cial Operations units implemented them quickly.
The next leadership step was the inclusion of medi-
cal training as one of the “Big Four” priorities for every
member of the 75th Ranger Regiment. Among the Rang-
ers, 100% were trained as first responders, 10% as emer-
gency medical technicians, and 3% as combat medics. This
meant that every member of the regiment was respon-
sible for casualty care of his fellow soldiers, and battle
commanders also had medical knowledge and training
that could be taken into consideration when making tac-
tical decisions. This is different from the majority of the
Armed Forces where medics are relied on heavily for ca-
sualty care. The Rangers developed a robust prehospital
registry to be able to track and improve processes. What
is remarkable is not only the outstanding survival of com-
plex injuries but also that fellow soldiers gave a substan-
tial portion of the lifesaving prehospital care.
This outstanding and commendable achievement is not
limited to the military—it has been previously shown in
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©2011 American Medical Association. All rights reserved.
43. Peake JB. Beyond the Purple Heart: continuity of care for the wounded in Iraq.
N Engl J Med. 2005;352(3):219-222.
44. Pruitt BA Jr. Combat casualty care and surgical progress. Ann Surg. 2006;243(6):
715-729.
45. Mabry RL, McManus JG. Prehospital advances in the management of severe pen-
etrating trauma. Crit Care Med. 2008;36(7)(suppl):S258-S266.
46. Cordts PR, Brosch LA, Holcomb JB. Now and then: combat casualty care poli-
cies for Operation Iraqi Freedom and Operation Enduring Freedom compared with
those of Vietnam. J Trauma. 2008;64(2)(suppl):S14-S20.
47. Tien HC, Jung V, Rizoli SB, Acharya SV, MacDonald JC. An evaluation of tactical
combat casualty care interventions in a combat environment. J Am Coll Surg.
2008;207(2):174-178.
48. US Department of Defense. Defense Health Board memorandum: Tactical Com-
bat Casualty Care and minimizing preventable fatalities in combat. August 6,
2009.
the challenging low-resource civilian environments of Cam-
bodia, Vietnam, Iraq, and Afghanistan, where the scourge
of land mines kill and injure civilian populations. Through
the leadership of the Trauma Care Foundation and the
Tromsø Mine Victim Resource Center, programs exist to
successfully train lay village workers through “village uni-
versities” as first responders for injuries.3 These civilian in-
juries share some similarities with the battlefield in that pre-
vention of other casualties must be ensured because the
victims are lying in a minefield and extremity hemor-
rhage and airway issues are common. As opposed to US
combat operations, there are unique low-resource chal-
lenges such as minimal local hospital resources leading to
prolonged prehospital transport times. Even with these chal-
lenges, Husum et al4 were able to show a reduction in the
mortality rate from 40% to 14.9% with a mean evacuation
time of 5.7 hours in a prospective study based in North Iraq
and Cambodia from 1997 to 2001. The measurable suc-
cess of programs that teach nonmedical personnel in pre-
hospital care and its outstanding effects on outcomes are
a lesson that I think is applicable to both military and low-
resource civilian environments. My hope is that these data
will serve as an impetus for the remainder of the Armed
Forces to adopt these lifesaving strategies.
Sherry M. Wren, MD
Author Affiliation: Department of Surgery, Stanford Uni-
versity School of Medicine, Palo Alto, California.
Correspondence: Dr Wren, Department of Surgery, Stan-
ford University School of Medicine, Palo Alto Veterans
Affairs Medical Center, 3801 Miranda Ave, Ste G112, Palo
Alto, CA 94304 (swren@stanford.edu).
Financial Disclosure: None reported.
1. Kouzes JM, Posner BZ. The Leadership Challenge. 4th ed. Hoboken, NJ: Jossey-
Bass; 2008.
2. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on
the battlefield [published online August 15, 2011]. Arch Surg. 2011; 146(12)1350-
1358.
3. Husum H, Gilbert M, Wisborg T. Save Lives, Save Limbs. Penang, Malaysia:
Third World Network; 2000.
4. Husum
H, Gilbert M, Wisborg T, Van Heng Y, Murad M. Rural prehospital trauma sys-
tems improve trauma outcome in low-income countries: a prospective study
from North Iraq and Cambodia. J Trauma. 2003;54(6):1188-1196.
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